Effectiveness of electrocardiographic guidance in CVAD tip placement

Background International standard practice for the correct confirmation of the central venous access device is the chest X-ray. The intracavitary electrocardiogram-based insertion method is radiation-free, and allows real-time placement verification, providing immediate treatment and reduced requirement for post-procedural repositioning. Methods Relevant databases were searched for prospective randomised controlled trials (RCTs) or quasi RCTs that compared the effectiveness of electrocardiogram-guided catheter tip positioning with placement using surface-anatomy-guided insertion plus chest X-ray confirmation. The primary outcome was accurate catheter tip placement. Secondary outcomes included complications, patient satisfaction and costs. Results Five studies involving 729 participants were included. Electrocardiogram-guided insertion was more accurate than surface anatomy guided insertion (odds ratio: 8.3; 95% confidence interval (CI) 1.38; 50.07; p=0.02). There was a lack of reporting on complications, patient satisfaction and costs. Conclusion The evidence suggests that intracavitary electrocardiogram-based positioning is superior to surface-anatomy-guided positioning of central venous access devices, leading to significantly more successful placements. This technique could potentially remove the requirement for post-procedural chest X-ray, especially during peripherally inserted central catheter (PICC) line insertion.

Design guidance for blast-resistant glazing

This paper reviews current design standards and test methods for blast-resistant glazing design and compares a typical design outcome with that from comprehensive finite-element (FE) analysis. Design standards are conservative and are limited to the design of relatively small glazed panels. Standard test methods are expensive, create environmental pollution, and can classify the hazard ratings of only smaller glazed panels. Here the design of a laminated glass (LG) panel is carried out according to an existing design standard, and then its performance is examined using comprehensive FE modeling and analysis. Finite-element results indicate that both glass panes crack, the interlayer yields with little damage, and the sealant joints do not fail for the designed blast load. This failure pattern satisfies some of the requirements for minimal hazard rating in the design standard. It is evident that interlayer thickness and material properties are important during the post-crack stage of an LG panel, but they are not accounted for in the design standards. The new information generated in this paper will contribute toward an enhanced blast design of LG panels.

Energy-based guidance of an underactuated unmanned underwater vehicle on a helical trajectory

This paper presents a motion control system for guidance of an underactuated Unmanned Underwater Vehicle (UUV) on a helical trajectory. The control strategy is developed using Port-Hamiltonian theory and interconnection and damping assignment passivity-based control. Using energy routing, the trajectory of a virtual fully actuated plant is guided onto a vector field. A tracking controller is then used that commands the underactuated plant to follow the velocity of the virtual plant. An integral control is inserted between the two control layers, which adds robustness and disturbance rejection to the design.

CBCT image guidance in head and neck irradiation: The impact of daily and weekly imaging protocols

Purpose This study evaluated the impact of a daily and weekly image-guided radiotherapy protocols in reducing setup errors and setting of appropriate margins in head and neck cancer patients. Materials and methods Interfraction and systematic shifts for the hypothetical day 1–3 plus weekly imaging were extrapolated from daily imaging data from 31 patients (964 cone beam computed tomography (CBCT) scans). In addition, residual setup errors were calculated by taking the average shifts in each direction for each patient based on the first three shifts and were presumed to represent systematic setup error. The clinical target volume (CTV) to planning target volume (PTV) margins were calculated using van Herk formula and analysed for each protocol. Results The mean interfraction shifts for daily imaging were 0·8, 0·3 and 0·5 mm in the S-I (superior-inferior), L-R (left-right) and A-P (anterior-posterior) direction, respectively. On the other hand the mean shifts for day 1–3 plus weekly imaging were 0·9, 1·8 and 0·5 mm in the S-I, L-R and A-P direction, respectively. The mean day 1–3 residual shifts were 1·5, 2·1 and 0·7 mm in the S-I, L-R and A-P direction, respectively. No significant difference was found in the mean setup error for the daily and hypothetical day 1–3 plus weekly protocol. However, the calculated CTV to PTV margins for the daily interfraction imaging data were 1·6, 3·8 and 1·4 mm in the S-I, L-R and A-P directions, respectively. Hypothetical day 1–3 plus weekly resulted in CTV–PTV margins of 5, 4·2 and 5 mm in the S-I, L-R and A-P direction. Conclusions The results of this study show that a daily CBCT protocol reduces setup errors and allows setup margin reduction in head and neck radiotherapy compared to a weekly imaging protocol.

Prevention and management of foot problems in diabetes: A summary guidance for daily practice 2015, based on the IWGDF Guidance Documents

In this 'Summary Guidance for Daily Practice', we describe the basic principles of prevention and management of foot problems in persons with diabetes. This summary is based on the International Working Group on the Diabetic Foot (IWGDF) Guidance 2015. There are five key elements that underpin prevention of foot problems: (1) identification of the at-risk foot; (2) regular inspection and examination of the at-risk foot; (3) education of patient, family and healthcare providers; (4) routine wearing of appropriate footwear, and; (5) treatment of pre-ulcerative signs. Healthcare providers should follow a standardized and consistent strategy for evaluating a foot wound, as this will guide further evaluation and therapy. The following items must be addressed: type, cause, site and depth, and signs of infection. There are seven key elements that underpin ulcer treatment: (1) relief of pressure and protection of the ulcer; (2) restoration of skin perfusion; (3) treatment of infection; (4) metabolic control and treatment of co-morbidity; (5) local wound care; (6) education for patient and relatives, and; (7) prevention of recurrence. Finally, successful efforts to prevent and manage foot problems in diabetes depend upon a well-organized team, using a holistic approach in which the ulcer is seen as a sign of multi-organ disease, and integrating the various disciplines involved.

IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes

Recommendations - 1 To identify a person with diabetes at risk for foot ulceration, examine the feet annually to seek evidence for signs or symptoms of peripheral neuropathy and peripheral artery disease. (GRADE strength of recommendation: strong; Quality of evidence: low) - 2 In a person with diabetes who has peripheral neuropathy, screen for a history of foot ulceration or lower-extremity amputation, peripheral artery disease, foot deformity, pre-ulcerative signs on the foot, poor foot hygiene and ill-fitting or inadequate footwear. (Strong; Low) - 3 Treat any pre-ulcerative sign on the foot of a patient with diabetes. This includes removing callus, protecting blisters and draining when necessary, treating ingrown or thickened toe nails, treating haemorrhage when necessary and prescribing antifungal treatment for fungal infections. (Strong; Low) - 4 To protect their feet, instruct an at-risk patient with diabetes not to walk barefoot, in socks only, or in thin-soled standard slippers, whether at home or when outside. (Strong; Low) - 5 Instruct an at-risk patient with diabetes to daily inspect their feet and the inside of their shoes, daily wash their feet (with careful drying particularly between the toes), avoid using chemical agents or plasters to remove callus or corns, use emollients to lubricate dry skin and cut toe nails straight across. (Weak; Low) - 6 Instruct an at-risk patient with diabetes to wear properly fitting footwear to prevent a first foot ulcer, either plantar or non-plantar, or a recurrent non-plantar foot ulcer. When a foot deformity or a pre-ulcerative sign is present, consider prescribing therapeutic shoes, custom-made insoles or toe orthosis. (Strong; Low) - 7 To prevent a recurrent plantar foot ulcer in an at-risk patient with diabetes, prescribe therapeutic footwear that has a demonstrated plantar pressure-relieving effect during walking (i.e. 30% relief compared with plantar pressure in standard of care therapeutic footwear) and encourage the patient to wear this footwear. (Strong; Moderate) - 8 To prevent a first foot ulcer in an at-risk patient with diabetes, provide education aimed at improving foot care knowledge and behaviour, as well as encouraging the patient to adhere to this foot care advice. (Weak; Low) - 9 To prevent a recurrent foot ulcer in an at-risk patient with diabetes, provide integrated foot care, which includes professional foot treatment, adequate footwear and education. This should be repeated or re-evaluated once every 1 to 3 months as necessary. (Strong; Low) - 10 Instruct a high-risk patient with diabetes to monitor foot skin temperature at home to prevent a first or recurrent plantar foot ulcer. This aims at identifying the early signs of inflammation, followed by action taken by the patient and care provider to resolve the cause of inflammation. (Weak; Moderate) - 11 Consider digital flexor tenotomy to prevent a toe ulcer when conservative treatment fails in a high-risk patient with diabetes, hammertoes and either a pre-ulcerative sign or an ulcer on the distal toe. (Weak; Low) - 12 Consider Achilles tendon lengthening, joint arthroplasty, single or pan metatarsal head resection, or osteotomy to prevent a recurrent foot ulcer when conservative treatment fails in a high-risk patient with diabetes and a plantar forefoot ulcer. (Weak; Low) - 13 Do not use a nerve decompression procedure in an effort to prevent a foot ulcer in an at-risk patient with diabetes, in preference to accepted standards of good quality care. (Weak; Low)

The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: Development of an evidence-based global consensus

Foot problems complicating diabetes are a source of major patient suffering and societal costs. Investing in evidence-based, internationally appropriate diabetic foot care guidance is likely among the most cost-effective forms of healthcare expenditure, provided it is goal-focused and properly implemented. The International Working Group on the Diabetic Foot (IWGDF) has been publishing and updating international Practical Guidelines since 1999. The 2015 updates are based on systematic reviews of the literature, and recommendations are formulated using the Grading of Recommendations Assessment Development and Evaluation system. As such, we changed the name from 'Practical Guidelines' to 'Guidance'. In this article we describe the development of the 2015 IWGDF Guidance documents on prevention and management of foot problems in diabetes. This Guidance consists of five documents, prepared by five working groups of international experts. These documents provide guidance related to foot complications in persons with diabetes on: prevention; footwear and offloading; peripheral artery disease; infections; and, wound healing interventions. Based on these five documents, the IWGDF Editorial Board produced a summary guidance for daily practice. The resultant of this process, after reviewed by the Editorial Board and by international IWGDF members of all documents, is an evidence-based global consensus on prevention and management of foot problems in diabetes. Plans are already under way to implement this Guidance. We believe that following the recommendations of the 2015 IWGDF Guidance will almost certainly result in improved management of foot problems in persons with diabetes and a subsequent worldwide reduction in the tragedies caused by these foot problems.

Open source computer-vision based guidance system for UAVs on-board decision making

The use of UAVs for remote sensing tasks; e.g. agriculture, search and rescue is increasing. The ability for UAVs to autonomously find a target and perform on-board decision making, such as descending to a new altitude or landing next to a target is a desired capability. Computer-vision functionality allows the Unmanned Aerial Vehicle (UAV) to follow a designated flight plan, detect an object of interest, and change its planned path. In this paper we describe a low cost and an open source system where all image processing is achieved on-board the UAV using a Raspberry Pi 2 microprocessor interfaced with a camera. The Raspberry Pi and the autopilot are physically connected through serial and communicate via MAVProxy. The Raspberry Pi continuously monitors the flight path in real time through USB camera module. The algorithm checks whether the target is captured or not. If the target is detected, the position of the object in frame is represented in Cartesian coordinates and converted into estimate GPS coordinates. In parallel, the autopilot receives the target location approximate GPS and makes a decision to guide the UAV to a new location. This system also has potential uses in the field of Precision Agriculture, plant pest detection and disease outbreaks which cause detrimental financial damage to crop yields if not detected early on. Results show the algorithm is accurate to detect 99% of object of interest and the UAV is capable of navigation and doing on-board decision making.

Promoting and providing expert guidance in work-intensive clinical settings

This paper discusses how expert guidance can be best provided in work intensive clinical settings. The adequacy for supporting learning in the clinical practicum for health care disciplines is often complicated by the intensive work practices in healthcare settings. Often, clinicians' work is so intense that the scope for providing close guidance for students is quite restricted. The case advanced here draws on a range of empirical work to propose how clinician-student interactions might be optimized through the provision of a clinical ccn guided learning such as demonstrating and role-modeling. These roles can contribute in essential ways to the development of learning environments where clinicians have the opportunity to facilitate the learning of others as part of their workload, and without being burdened by the requirements of teaching and assessment processes. It differs from other approaches because although clinicians partner students and provide feedback to them, clinicians are not expected to formally assess or award a grade for student performance. Assessment and remedial action, when required, is undertaken by the role of a designated clinical supervisor qualified to perform such activities. © 2010 Springer Science+Business Media B.V.

A Framework of Issues in Large Process Modelling Projects

As process management projects have increased in size due to globalised and company-wide initiatives, a corresponding growth in the size of process modeling projects can be observed. Despite advances in languages, tools and methodologies, several aspects of these projects have been largely ignored by the academic community. This paper makes a first contribution to a potential research agenda in this field by defining the characteristics of large-scale process modeling projects and proposing a framework of related issues. These issues are derived from a semi -structured interview and six focus groups conducted in Australia, Germany and the USA with enterprise and modeling software vendors and customers. The focus groups confirm the existence of unresolved problems in business process modeling projects. The outcomes provide a research agenda which directs researchers into further studies in global process management, process model decomposition and the overall governance of process modeling projects. It is expected that this research agenda will provide guidance to researchers and practitioners by focusing on areas of high theoretical and practical relevance.

An interpretative phenomenological analysis of adult clients’ experience of My Career Chapter

This paper presents an investigation into the properties of a new narrative technique for career assessment and counselling, My Career Chapter: A Dialogical Autobiography. This technique is used to facilitate clients’ construction of a meaningful career-related autobiography. Previous research indicates the usefulness of My Career Chapter for adult clients and its alignment with recommendations for the development and application of qualitative assessment and counselling techniques. This study specifically commences research into the technique’s applicability for adolescents. A focus group, comprised of guidance counselling professionals whose work primarily pertained to the needs of adolescents, found that there is potential to develop a version of My Career Chapter that is suitable for adolescents.

Context and models for the analysis of individual and group needs

This paper summarizes the papers presented in the thematic stream Models for the Analysis of Individual and Group Needs, at the 2007 IAEVG-SVP-NCDA Symposium: Vocational Psychology and Career Guidance Practice: An International Partnership. The predominant theme which emerged from the papers was that theory and practice need to be positioned within their contexts. For this paper, context has been formulated as a dimension ranging from the individual’s experience of himself or herself in conversations, including interpersonal transactions and body culture, through to broad higher levels of education, work, nation, and economy.